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Raveendran AV, Chacko EC, Pappachan JM. Non-pharmacological Treatment Options in the Management of Diabetes Mellitus. EUROPEAN ENDOCRINOLOGY 2018; 14:31-39. [PMID: 30349592 PMCID: PMC6182920 DOI: 10.17925/ee.2018.14.2.31] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/13/2018] [Indexed: 02/05/2023]
Abstract
The global prevalence of diabetes, especially type 2 diabetes mellitus, has reached epidemic proportions in the last few decades of the 20th century because of the obesity pandemic resulting from adverse lifestyles. Diabetes as a consequence of obesity (diabesity), continues to increase exponentially in the 21st century. Although there are a multitude of drugs for the effective management of diabesity with modest benefits, most patients will require insulin for control of diabetes at some stage that would worsen obesity, and thereby diabesity. Therefore, effective non-pharmacological therapy needs to be expedited in all patients with diabesity. These measures include medical nutrition interventions, change of lifestyles and bariatric surgery. Non-pharmacological interventions are also useful for the effective management of even type 1 diabetes mellitus when used along with insulin therapy especially in those with obesity. This review summarises the current evidence base for the non-pharmacological interventions in the management of diabetes.
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Affiliation(s)
| | - Elias C Chacko
- Department of Endocrinology, Jersey General Hospital, Jersey
| | - Joseph M Pappachan
- Department of Endocrinology, Diabetes & Metabolism, University Hospitals of Morecambe Bay NHS Foundation Trust, UK
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Abstract
PURPOSE OF REVIEW Enhanced recovery pathways are a well-defined perioperative health care program utilizing evidence-based interventions in a protocol-like manner designed to standardize techniques including drug selection and dosing to improve results and to reduce overall costs including facilitating earlier discharge from hospitals after surgery. RECENT FINDINGS A PubMed and World Wide Web search was performed with the following key words: enhanced recovery, surgical enhanced recovery, recovery pathways, and enhanced recovery pathways surgery. This introduction to enhanced recovery pathways reflects its 20-year history, worldwide appeal, and ever growing presence in our practices. Many clinical teams have not, as of yet, incorporated enhanced recovery pathway principles to their practices and therefore, continued evolution should include increasing outreach and formalized guidelines in the future.
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303
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An ERAS protocol for bariatric surgery: is it safe to discharge on post-operative day 1? Surg Endosc 2018; 33:580-586. [PMID: 30120584 DOI: 10.1007/s00464-018-6368-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/20/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy is the most commonly performed bariatric surgery in the world. Enhanced recovery after surgery (ERAS) protocols have been shown to reduce complications and decrease length of stay for various types of surgeries. In this study, we propose an ERAS protocol for laparoscopic sleeve gastrectomy and compare the clinical outcomes with patients who received standard care. METHODS We performed a single-institution retrospective analysis in patients who underwent laparoscopic sleeve gastrectomy from February 2015 to December 2017. Patients were stratified into standard care and ERAS protocol groups. The ERAS protocol consisted of goal-directed patient education, specific pre- and post-op multi-modal medication regimen, early ambulation, and early oral intake. Patients were discharged on their first post-operative day if they met appropriate post-surgical milestones. The primary outcomes were length of stay, 7- and 30-day readmission rates, and complication rates. Secondary outcomes included anti-emetic and pain medication utilization, post-operative emesis episodes per day, post-operative pain scores, and mortality. RESULTS We included 214 consecutive patients who underwent sleeve gastrectomy, 130 were in the ERAS group and 84 were in the standard care group. Median hospital stay was significantly shorter in the ERAS group compared to the standard care group (1 vs. 2 days; p < 0.001). There were no differences in 7- or 30-day readmission rates (1.5 vs. 1.2%; p = 0.838, 2.3 vs. 2.4%; p = 0.966) or post-operative complications (6.2 vs. 3.6%; p = 0.410). The ERAS group also had decreased median intra-operative opioid consumption and self-reported pain scores on post-operative day 1 (27.5 MME vs. 27.4 MME; p = 0.044, 3.3 vs. 3.9; p = 0.046). Mortality rate was 0% overall. CONCLUSION A cost-effective ERAS protocol for laparoscopic sleeve gastrectomy results in shorter length of stay, without increase in peri-operative morbidity or readmission rates.
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304
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Early intake of solid food after Roux-en-Y gastric bypass and complications. A cohort study from the Scandinavian Obesity Surgery Registry. Surg Obes Relat Dis 2018; 14:1256-1260. [PMID: 30001890 DOI: 10.1016/j.soard.2018.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/17/2018] [Accepted: 05/26/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. There are few studies investigating how early return to solid food affects complications. OBJECTIVE The aim of this study was to explore how oral intake was resumed in RYGB patients and how the postoperative food regimen affects outcomes, such as complications and length of stay. SETTING Retrospective nationwide registry study. METHODS The Scandinavian Obesity Surgery Registry included prospective data from RYGB patients operated in 2009 to 2014. A questionnaire assessed the postoperative reintroduction of solid food applied at each bariatric center. The postoperative regimen was established in 23,589 patients. Outcomes were recorded at 30-day follow-up according to the standard Scandinavian Obesity Surgery Registry routine. RESULTS Nine percent of patients (n = 2074) returned to solid food within the first week after surgery. Most commonly solid food was resumed in week 4 (37%, n = 8659). Median length of stay was 2 days for all. Of all, 2.8% suffered from a severe complication (>Clavien-Dindo 3a). After adjusting for the annual volume of procedures at hospitals, there was no correlation that the timing of solid food affected complication rates. The odds ratio for a severe complication was significantly lower for intermediate- (odds ratio .64 95% confidence interval .48-.85) or high- (odds ratio .52 95% confidence interval .42-.66) volume centers. The rate of leaks and small bowel obstructions were evenly distributed between the different postoperative food regimens. CONCLUSION Early return to solid food after RYGB did not affect the risk of severe complications. Patients operated at centers with an annual volume of >100 procedures have a lower risk of severe complications.
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305
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Sosa JA, Ljungqvist O. World Journal of Surgery Becomes the Official Publication of the ERAS Society. World J Surg 2018; 42:2689-2690. [PMID: 29959489 DOI: 10.1007/s00268-018-4724-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Julie Ann Sosa
- Department of Surgery, University of California at San Francisco-UCSF, San Francisco, CA, USA.
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306
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Howard ML, Steuber TD, Nisly SA. Glycemic Management in the Bariatric Surgery Population: A Review of the Literature. Pharmacotherapy 2018; 38:663-673. [DOI: 10.1002/phar.2120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Meredith L. Howard
- Department of Pharmacotherapy; University of North Texas System College of Pharmacy; Fort Worth Texas
| | - Taylor D. Steuber
- Department of Pharmacy Practice; Auburn University Harrison School of Pharmacy; Huntsville Alabama
| | - Sarah A. Nisly
- Wingate University School of Pharmacy; Wingate North Carolina
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307
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Major P, Małczak P, Wysocki M, Torbicz G, Gajewska N, Pędziwiatr M, Budzyński A. Bariatric patients' nutritional status as a risk factor for postoperative complications, prolonged length of hospital stay and hospital readmission: A retrospective cohort study. Int J Surg 2018; 56:210-214. [PMID: 29933099 DOI: 10.1016/j.ijsu.2018.06.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 05/21/2018] [Accepted: 06/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The prevalence of obesity is growing worldwide. Malnutrition has been identified as a risk factor, leading to higher morbidity rate and prolonged length of hospital. So far there are no high quality data on the impact of malnutrition on length of hospital stay and morbidity regarding bariatric surgery. The aim of the study was to assess association between nutritional status and outcomes bariatric surgeries. MATERIAL AND METHODS The study was a prospective observational study. INCLUSION CRITERIA informed consent to participate in the study, age 18-65 years, meeting the eligibility criteria for bariatric treatment, qualification for laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y Gastric By-pass (LRYGB). EXCLUSION CRITERIA revision surgery, lack of necessary data. The primary endpoint was the evaluation of protein malnutrition risk prevalence. Secondary: influence of malnutrition risk patients' on treatment course and postoperative complications. RESULTS 533 patients met inclusion criteria and were analyzed. 169 patients (32%) had qualitative risk of malnutrition. The body mass index (BMI) was significantly higher in malnutritioned group, p = 0.001. Albumins in malnutritioned group was 38 g/l (IQR 35-42), whereas in control group it was 41 g/l (IQR 39-43), p = 0.027. Lymphocyte count in malnutrition risk group and control group were 1.24 10'3/μl (IQR 1.1-1.37) and 1.94 10'3/μl (IQR1.7-2.3) respectively, p < 0.001. In linear regression model, a correlation between BMI and total number of lymphocytes was present, p < 0.001. Malnutrition risk did not affect the total morbidity rate. There was a difference in occurrence of postoperative nausea and vomiting, p = 0.033. CONCLUSIONS Higher BMI is associated with greater risk of malnutrition. Proper perioperative care may diminish the impact of malnutrition on adverse effects and length of stay (LOS).
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Affiliation(s)
- Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Michał Wysocki
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Grzegorz Torbicz
- Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland.
| | - Natalia Gajewska
- Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland.
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
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308
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Meta-Analysis of Enhanced Recovery Protocols in Bariatric Surgery. J Gastrointest Surg 2018; 22:964-972. [PMID: 29488124 DOI: 10.1007/s11605-018-3709-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 02/05/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) guidelines, fast-track protocols, and alternative clinical pathways have been widely promoted in a variety of disciplines leading to improved outcomes in post-operative morbidity and length of stay (LOS). This meta-analysis assesses the implications of standardized management protocols in bariatric surgery. METHODS The PRISMA guidelines were adhered to. Databases were searched with the application of pre-defined inclusion and exclusion criteria. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). Individual protocols and surgical approaches were assessed through subgroup analysis, and sensitivity analysis of methodological quality was performed. RESULTS A total of 1536 studies were screened; 13 studies were eventually included for meta-analysis involving a total of 6172 patients. Standardized perioperative techniques were associated with a savings of 19.5 min in operative time (p < 0.01), as well as a LOS which was shortened by 1.5 days (p < 0.01). Pooled post-operative morbidity rates also favored enhanced recovery care protocols (OR 0.7%, 95% CI 0.6-0.9%, p < 0.01). CONCLUSION Bariatric surgery involves a complex cohort of patients who require high-quality evidence-based care to improve outcomes. Consensus guidelines on the feasibility of ERAS and alternative clinical pathways are required in the setting of bariatric surgery.
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309
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Borggreve AS, Kingma BF, Domrachev SA, Koshkin MA, Ruurda JP, Hillegersberg R, Takeda FR, Goense L. Surgical treatment of esophageal cancer in the era of multimodality management. Ann N Y Acad Sci 2018; 1434:192-209. [DOI: 10.1111/nyas.13677] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/05/2018] [Accepted: 02/23/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Alicia S. Borggreve
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
- Moscow Clinical Scientific Center Moscow Russia
| | - B. Feike Kingma
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
| | | | | | - Jelle P. Ruurda
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
| | - Richard Hillegersberg
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
| | - Flavio R. Takeda
- Sao Paulo Institute of CancerUniversity of Sao Paulo School of Medicine Sao Paulo Brazil
| | - Lucas Goense
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
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310
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Burgess LC, Immins T, Wainwright TW. What is the role of post-operative physiotherapy in general surgical Enhanced Recovery after Surgery pathways? EUROPEAN JOURNAL OF PHYSIOTHERAPY 2018. [DOI: 10.1080/21679169.2018.1468813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Louise C. Burgess
- Orthopaedic Research Institute, Bournemouth University, Bournemouth, UK
| | - Tikki Immins
- Orthopaedic Research Institute, Bournemouth University, Bournemouth, UK
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311
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Harris J. Success of a Colorectal Surgical Site Infection Prevention Bundle in a Multihospital System. AORN J 2018; 107:592-600. [DOI: 10.1002/aorn.12124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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312
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Lin S, Guan W, Hans P, Liang H. Status of Laparoscopic Sleeve Gastrectomy in China: A National Survey. Obes Surg 2018; 27:2968-2973. [PMID: 28527155 DOI: 10.1007/s11695-017-2727-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is a favorable bariatric procedure. This study evaluated the status of LSG in China. METHODS During the 4th International Forum of Bariatric and Metabolic Surgery in May 2016, Nanjing China, an on-the-spot questionnaire was filled out by 105 attending surgeons with experience of LSG. The feedback data was collected and analyzed. RESULTS For preoperative preparations, surgeons preferred blood glucose control with insulin (61.0%), bowel cleaning (33.3%), and fasting and water deprivation (75.2%). For surgical techniques, surgeons preferred 36/38F bougie (86.7%), greater curvature mobilization with ultrasonic energy device (89.5%), direct transection of short gastric vessels (80%), antrum resection within 2-6 cm to the pylorus (84.8%) with 4.8 mm height stapler (72.4%), and 3.5 mm for corpus (94.3%). Whole stapler-line reinforcement, gastric sleeve fixation, leaking test, and abdominal drainage were preferred by 48.6, 62.9, 39, and 47.6% surgeons. For postoperative managements, surgeons preferred nasogastric tube insertion (33.3%), early liquid diet (69.6%), 4 weeks of liquid diet (55.2%), 2000 ml daily water intake before discharge (79%), 4 weeks of PPI (69.5%), and multi-vitamin supplementation 1 week after operation (77.1%). For postoperative complications, preferences were tachycardia as the onset of leak (81.0%) and oral contrast radiography for leak diagnosis (72.4%). Leak managements include US-guided percutaneous drainage (68.6%), nasogastric tube (87.6%), and parenteral nutrition (61%). For prolonged leak, enteral nutrition (87.6%) and Roux-en-Y bypass (84.8%) as the salvage procedure were preferred. 95.2% preferred endoscopic dilation for stricture. CONCLUSIONS LSG is gaining its wide application in China, but standardization of LSG is urgently needed.
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Affiliation(s)
- Shibo Lin
- Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - Wei Guan
- Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - Pankaj Hans
- Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - Hui Liang
- Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China.
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313
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Comparison of the Recovery Profile between Desflurane and Sevoflurane in Patients Undergoing Bariatric Surgery-a Meta-Analysis of Randomized Controlled Trials. Obes Surg 2018; 27:3031-3039. [PMID: 28916989 DOI: 10.1007/s11695-017-2929-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Early and clear recovery from anesthesia is the crux for preventing perioperative complications in the obese undergoing bariatric surgery. Volatile inhalation agents by virtue of high lipid solubility are expected to produce residual anesthetic effects. Prospective randomized trials comparing desflurane and sevoflurane used for anesthesia maintenance (electroencephalograph guided) during bariatric surgery published till 1st of July 2017 were searched in the medical database. Comparisons were made for surrogate markers of recovery from anesthesia that included time to eye-opening (TEo), time to tracheal-extubation (TEx), and Aldrete scores on immediately shifting to recovery (Ald-I). Five trials were included in the final analysis. Patients receiving desflurane began to respond faster by opening eyes on command (five trials) by 3.80 min (95%CI being 1.83-5.76) (random effects, P < 0.01, I2 = 78.61%), and tracheal extubation was also performed earlier (four trials) by 4.97 min (95%CI being 1.34-8.59). This meant a reduction of 37% in TEo and 33.60% in TEx over sevoflurane. Ald-I scores were higher/better with desflurane by 0.52 (95%CI being 0.19-0.84) (Fixed-effects, P < 0.01, I2 = 6.67%). Publication bias is likely for TEo (Egger's Test, X-intercept = - 8.57, P = 0.02). No airway-related complications were reported with desflurane's expedited recovery. Use of desflurane compared to sevoflurane for maintenance of anesthesia in morbidly obese patients allows attaining verbal contact faster, and tracheal extubating can be performed earlier without compromising safety. The benefits of better recovery extend into the immediate postoperative phase with patients being more awake upon shifting to the recovery.
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314
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Decreasing length of stay in bariatric surgery: The power of suggestion. Am J Surg 2018; 215:452-455. [DOI: 10.1016/j.amjsurg.2017.09.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/29/2017] [Accepted: 09/30/2017] [Indexed: 12/20/2022]
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315
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The Successful Implementation of a Modified Enhanced Recovery After Surgery (ERAS) Program for Bariatric Surgery in a South African Teaching Hospital. Surg Laparosc Endosc Percutan Tech 2018; 28:26-29. [DOI: 10.1097/sle.0000000000000488] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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316
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Mahmood F, Sharples AJ, Rotundo A, Balaji N, Rao VSR. Factors Predicting Length of Stay Following Bariatric Surgery: Retrospective Review of a Single UK Tertiary Centre Experience. Obes Surg 2018; 28:1924-1930. [DOI: 10.1007/s11695-017-3105-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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317
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Blanchet MC, Gignoux B, Matussière Y, Vulliez A, Lanz T, Monier F, Frering V. Experience with an Enhanced Recovery After Surgery (ERAS) Program for Bariatric Surgery: Comparison of MGB and LSG in 374 Patients. Obes Surg 2018; 27:1896-1900. [PMID: 28455803 DOI: 10.1007/s11695-017-2694-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Strategic multidisciplinary protocols for "enhanced recovery after surgery" (ERAS) have demonstrated reductions in length of hospital stay (LOS), morbidity, and costs in conjunction with bariatric procedures. METHODS We prospectively investigated the effectiveness and safety of an ERAS protocol with laparoscopic omega loop gastric bypass ("mini" gastric bypass, MGB) and LSG in morbidly obese patients. RESULTS Average LOS was 1.24 days (range 1-14); 86.1% discharged on day 1; 96.9% by day 2, a value comparable or better than that of other ERAS studies vs standard care according to meta-analysis. Complications 2.9%; readmission 2.1%; reintervention 1.3%. CONCLUSION The program was equally safe with both procedures. Postoperative antithrombotic heparin does not appear necessary in low-risk patients. Bariatric surgical ERAS programs are evolving and not yet standardized.
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Affiliation(s)
- Marie-Cécile Blanchet
- Clinique de la Sauvegarde, Lyon, France. .,Espace Médico-Chirurgical, Immeuble ''Trait d'Union'', Entrée A29 Av des Sources, 69009, Lyon, France.
| | | | - Yann Matussière
- Clinique de la Sauvegarde, Lyon, France.,Department of Nutrition 29 avenue des Sources- Clinique de la Sauvegarde, 69009, Lyon, France
| | - Alexandre Vulliez
- Clinique de la Sauvegarde, Lyon, France.,Department of anesthesiology - 29 avenue des Sources- Clinique de la Sauvegarde, 69009, Lyon, France
| | - Thomas Lanz
- Clinique de la Sauvegarde, Lyon, France.,Department of anesthesiology - 29 avenue des Sources- Clinique de la Sauvegarde, 69009, Lyon, France
| | - Fabienne Monier
- Clinique de la Sauvegarde, Lyon, France.,Department of anesthesiology - 29 avenue des Sources- Clinique de la Sauvegarde, 69009, Lyon, France
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318
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Implementation of enhanced recovery programs for bariatric surgery. Results from the Francophone large-scale database. Surg Obes Relat Dis 2018; 14:99-105. [DOI: 10.1016/j.soard.2017.09.535] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/13/2017] [Accepted: 09/28/2017] [Indexed: 02/06/2023]
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319
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MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health 2017; 1:e381-e388. [PMID: 29851650 DOI: 10.1016/s2542-5196(17)30162-6] [Citation(s) in RCA: 290] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 10/13/2017] [Accepted: 11/21/2017] [Indexed: 05/05/2023]
Abstract
BACKGROUND Climate change is a major global public health priority. The delivery of health-care services generates considerable greenhouse gas emissions. Operating theatres are a resource-intensive subsector of health care, with high energy demands, consumable throughput, and waste volumes. The environmental impacts of these activities are generally accepted as necessary for the provision of quality care, but have not been examined in detail. In this study, we estimate the carbon footprint of operating theatres in hospitals in three health systems. METHODS Surgical suites at three academic quaternary-care hospitals were studied over a 1-year period in Canada (Vancouver General Hospital, VGH), the USA (University of Minnesota Medical Center, UMMC), and the UK (John Radcliffe Hospital, JRH). Greenhouse gas emissions were estimated using primary activity data and applicable emissions factors, and reported according to the Greenhouse Gas Protocol. FINDINGS Site greenhouse gas evaluations were done between Jan 1 and Dec 31, 2011. The surgical suites studied were found to have annual carbon footprints of 5 187 936 kg of CO2 equivalents (CO2e) at JRH, 4 181 864 kg of CO2e at UMMC, and 3 218 907 kg of CO2e at VGH. On a per unit area basis, JRH had the lowest carbon intensity at 1702 kg CO2e/m2, compared with 1951 kg CO2e/m2 at VGH and 2284 kg CO2e/m2 at UMMC. Based on case volumes at all three sites, VGH had the lowest carbon intensity per operation at 146 kg CO2e per case compared with 173 kg CO2e per case at JRH and 232 kg CO2e per case at UMMC. Anaesthetic gases and energy consumption were the largest sources of greenhouse gas emissions. Preferential use of desflurane resulted in a ten-fold difference in anaesthetic gas emissions between hospitals. Theatres were found to be three to six times more energy-intense than the hospital as a whole, primarily due to heating, ventilation, and air conditioning requirements. Overall, the carbon footprint of surgery in the three countries studied is estimated to be 9·7 million tonnes of CO2e per year. INTERPRETATION Operating theatres are an appreciable source of greenhouse gas emissions. Emissions reduction strategies including avoidance of desflurane and occupancy-based ventilation have the potential to lessen the climate impact of surgical services without compromising patient safety. FUNDING None.
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Affiliation(s)
- Andrea J MacNeill
- Division of General Surgery, University of British Columbia, Vancouver, Canada; Environmental Change Institute, School of Geography and the Environment, University of Oxford, Oxford, UK.
| | | | - Carl J Brown
- Division of General Surgery, University of British Columbia, Vancouver, Canada
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320
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Sultana A, Torres D, Schumann R. Special indications for Opioid Free Anaesthesia and Analgesia, patient and procedure related: Including obesity, sleep apnoea, chronic obstructive pulmonary disease, complex regional pain syndromes, opioid addiction and cancer surgery. Best Pract Res Clin Anaesthesiol 2017; 31:547-560. [DOI: 10.1016/j.bpa.2017.11.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 11/09/2017] [Indexed: 12/18/2022]
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321
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Mauermann E, Ruppen W, Bandschapp O. Different protocols used today to achieve total opioid-free general anesthesia without locoregional blocks. Best Pract Res Clin Anaesthesiol 2017; 31:533-545. [DOI: 10.1016/j.bpa.2017.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 08/08/2017] [Accepted: 11/08/2017] [Indexed: 12/20/2022]
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Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines. Anesthesiol Clin 2017; 35:e115-e143. [PMID: 28526156 DOI: 10.1016/j.anclin.2017.01.018] [Citation(s) in RCA: 240] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.
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Małczak P, Pisarska M, Piotr M, Wysocki M, Budzyński A, Pędziwiatr M. Enhanced Recovery after Bariatric Surgery: Systematic Review and Meta-Analysis. Obes Surg 2017; 27:226-235. [PMID: 27817086 PMCID: PMC5187372 DOI: 10.1007/s11695-016-2438-z] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocol is well established in many surgical disciplines and leads to a decrease in the length of hospital stay and morbidity. Multimodal protocols have also been introduced to bariatric surgery. This review aims to evaluate the current literature on ERAS in obesity surgery and to conduct a meta-analysis of primary and secondary outcomes. MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. Key journals were hand-searched. We analysed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was the length of hospital stay; the secondary outcomes included overall morbidity, specific complications, mortality, readmissions and costs. Random effect meta-analyses were undertaken. The initial search yielded 1151 articles. Thorough evaluation resulted in 11 papers, which were analysed. The meta-analysis of the length of stay presented a significant reduction standard mean difference (Std. MD) = −2.39 (−3.89, −0.89), p = 0.002. The analysis of overall morbidity, specific complications and Clavien-Dindo classification showed no significant variations among the study groups. ERAS protocol in bariatric surgery leads to the reduction of the length of hospital stay while maintaining no or low influence on morbidity.
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Affiliation(s)
- Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Major Piotr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Michał Wysocki
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kopernika 21, 31-501, Kraków, Poland.
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324
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Senturk JC, Kristo G, Gold J, Bleday R, Whang E. The Development of Enhanced Recovery After Surgery Across Surgical Specialties. J Laparoendosc Adv Surg Tech A 2017; 27:863-870. [PMID: 28795911 DOI: 10.1089/lap.2017.0317] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS®) principles have gained traction in variety of surgical disciplines. The promise of a reduced length of stay without compromising patient safety or increasing readmission rates has produced a body of literature examining the implementation of ERAS in the care of general, thoracic, urologic, and gynecologic surgery patients. METHODS We performed a review of the literature pertaining to studies of ERAS implementation across colorectal surgery, general surgery, thoracic surgery, urology, and gynecology. The extent of ERAS implementation and reported outcomes across key studies as well as systematic reviews and meta-analyses in each field were summarized. RESULTS The implementation of ERAS protocols has not been uniform across surgical specialties. Despite this, ERAS has produced improvements in patient outcomes. The most commonly described benefit of ERAS application has been reduced length of stay; complication and readmission rates are most consistently decreased in the colorectal literature. Studies have started to measure more nuanced measures of postoperative patient well-being. Efforts are growing to standardize ERAS protocols across diverse fields and call attention to the need for quality control. CONCLUSIONS Challenges remain in the study and execution of ERAS. Controlling for adherence to ERAS components and implementing uniform ERAS protocols across studies are burgeoning topics that have significant implications for study design. The practice of ERAS and its benefits to patients are expected to evolve. Assessing improvements in postdischarge quality of life, timing of return to work and independent living, and adherence to scheduled delivery of adjuvant treatments will strengthen future ERAS investigations.
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Affiliation(s)
- James C Senturk
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts
| | - Gentian Kristo
- 2 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
| | - Jason Gold
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
| | - Ronald Bleday
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts
| | - Edward Whang
- 1 Department of Surgery, Brigham and Women's Hospital/Harvard Medical School , Boston, Massachusetts.,2 Department of Surgery, VA Boston Healthcare System , West Roxbury, Massachusetts
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325
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De-Marchi JJ, De-Souza MM, Salomão AB, Nascimento JEDA, Selleti AA, de-Albuquerque E, Mendes KBV. Perioperative care in bariatric surgery in the context of the ACERTO project: reality versus surgeons assumptions in a Cuiabá hospital. Rev Col Bras Cir 2017; 44:270-277. [PMID: 28767803 DOI: 10.1590/0100-69912017003009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/02/2017] [Indexed: 11/22/2022] Open
Abstract
Objective: to assess the level of knowledge among bariatric surgeons, about the recommendations of the ACERTO Project, correlating their assumptions on their perioperative prescriptions and the reality, according to the patients charts. Method: we conducted a prospective, longitudinal, observational study comparing the assumptions of bariatric surgeons obtained through responses on a specific questionnaire with the reality found in clinical data from the hospital records. We analyzed the following variables: preoperative fasting, early postoperative feeding, intravenous hydration, perioperative antibiotic prophylaxis, use of abdominal drains, type of analgesia, and prophylaxis of nausea and vomiting. We confronted the responses of seven surgeons with data from 200 records of patients undergoing gastroplasty for morbid obesity. Results: all interviewed surgeons knew the ACERTO Project. Five (72%) responded that they followed the protocol thoroughly. The median time of preoperative fasting found in the records was higher than the reported by the surgeons (p<0.05). Early postoperative feeding was prescribed for 96.5% of cases. The median volume of intravenous fluids prescribed in the first 24 hours was 4000ml, which was consistent with the interviews. There were no differences between the response in the questionnaire and the findings in the hospital records in relation to antibiotic prophylaxis, use of catheters and drains, analgesia and prophylaxis of nausea and vomiting. Conclusion: the ACERTO Project was well practiced among the surveyed surgeons. There was a good correlation between their assumptions and the reality in perioperative care of patients undergoing bariatric surgery. However, there was a significant difference in preoperative fasting time.
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326
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Singh PM, Panwar R, Borle A, Mulier JP, Sinha A, Goudra B. Perioperative analgesic profile of dexmedetomidine infusions in morbidly obese undergoing bariatric surgery: a meta-analysis and trial sequential analysis. Surg Obes Relat Dis 2017; 13:1434-1446. [DOI: 10.1016/j.soard.2017.02.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/05/2017] [Accepted: 02/25/2017] [Indexed: 11/16/2022]
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327
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36:623-650. [DOI: 10.1016/j.clnu.2017.02.013] [Citation(s) in RCA: 965] [Impact Index Per Article: 137.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 02/07/2023]
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328
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Telem DA, Gould J, Pesta C, Powers K, Majid S, Greenberg JA, Teixeira A, Brounts L, Lin H, DeMaria E, Rosenthal R. American Society for Metabolic and Bariatric Surgery: care pathway for laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2017; 13:742-749. [DOI: 10.1016/j.soard.2017.01.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 02/06/2023]
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329
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Major P, Wysocki M, Dworak J, Pędziwiatr M, Małczak P, Budzyński A. Are bariatric operations performed by residents safe and efficient? Surg Obes Relat Dis 2017; 13:614-621. [DOI: 10.1016/j.soard.2016.11.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/03/2016] [Accepted: 11/19/2016] [Indexed: 01/11/2023]
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330
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Comparison of circular- and linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass: a multicenter study. Wideochir Inne Tech Maloinwazyjne 2017; 12:140-146. [PMID: 28694899 PMCID: PMC5502334 DOI: 10.5114/wiitm.2017.66868] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/15/2017] [Indexed: 01/16/2023] Open
Abstract
Introduction Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common, well-established procedure, but no consensus regarding selection of the gastrojejunostomy (GJ) technique has been reached, and standardization of this precise technique is far from being achieved. Aim To compare circular-stapled and linear-stapled GJ in LRYGB in terms of operative time and postoperative complications. Material and methods This retrospective case-control study compared the perioperative and postoperative outcomes of LRYGB with a circular-stapled (LRYGB-CS) versus linear-stapled (LRYGB-LS) gastrojejunostomy. All patients, operated on in two academic referral care centers for bariatric surgery, were enrolled from April 2013 to June 2016. 457 patients were included (255 and 202 respectively in the LRYGB-CS and LRYGB-LS groups). After matching the groups for age, sex, body mass index, arterial hypertension, and presence of type 2 diabetes in a 1 : 1 ratio, 99 patients were enrolled in each. Results The total operative time was longer in the LRYGB-LS group (140 vs. 85 min, p < 0.001). The postoperative hemorrhage and wound infection rates were lower in the LRYGB-LS group (2.1% vs. 10.3%, p = 0.021, and 1.0% vs. 9.3%, p = 0.011). The readmission rates were comparable (8.2% vs. 6.1%, p = 0.593). There was no significant difference in the incidence of gastrojejunostomy leakage, stricture, port-site hernia, or marginal ulcer. Conclusions Both anastomosis types for LRYGB are safe and have low and comparable risks of postoperative complications. After LRYGB-CS, postoperative bleeding and wound infections are slightly more frequent; however, the operative time is shorter.
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331
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Pisarska M, Małczak P, Major P, Wysocki M, Budzyński A, Pędziwiatr M. Enhanced recovery after surgery protocol in oesophageal cancer surgery: Systematic review and meta-analysis. PLoS One 2017; 12:e0174382. [PMID: 28350805 PMCID: PMC5370110 DOI: 10.1371/journal.pone.0174382] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/08/2017] [Indexed: 12/16/2022] Open
Abstract
Background Enhanced Recovery After Surgery (ERAS) protocol are well established in many surgical disciplines, leading to decrease in morbidity and length of hospital stay. These multi-modal protocols have been also introduced to oesophageal cancer surgery. This review aimed to evaluate current literature on ERAS in oesophageal cancer surgery and conduct a meta-analysis on primary and secondary outcomes. Methods MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. We analyzed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was overall morbidity. Secondary outcomes included length of hospital stay, specific complications, mortality and readmissions. Random effect meta-analyses were undertaken. Results Initial search yielded 1,064 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. A total of 2,042 patients were included in the analysis (1,058 ERAS group and 984 treated with traditional protocols). Analysis of overall morbidity as well as complication rate did not show any significant reduction. Non-surgical complications and pulmonary complications were significantly lower in the ERAS group, RR = 0.71 95% CI 0.62–0.80, p < 0.00001 and RR = 0.75, 95% CI 0.60–0.94, p = 0.01, respectively. Meta-analysis on length of stay presented significant reduction Mean difference = -3.55, 95% CI -4.41 to -2.69, p for effect<0.00001. Conclusions This systematic review with a meta-analysis on ERAS in oesophageal surgery indicates a reduction of non-surgical complications and no negative influence on overall morbidity. Moreover, a reduction in the length of hospital stay was presented.
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Affiliation(s)
- Magdalena Pisarska
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Piotr Małczak
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Piotr Major
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Wysocki
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Andrzej Budzyński
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
| | - Michał Pędziwiatr
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
- Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Kraków, Poland
- * E-mail:
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Dai J, Jiang Y, Fu D. Reducing postoperative complications and improving clinical outcome: Enhanced recovery after surgery in pancreaticoduodenectomy - A retrospective cohort study. Int J Surg 2017; 39:176-181. [PMID: 28132917 DOI: 10.1016/j.ijsu.2017.01.089] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND An enhanced recovery after surgery (ERAS) programme aims to reduce the stress response to surgery and thereby accelerate recovery. The experience of implementing the ERAS programmes in pancreatoduodenectomy (PD) is relatively limited. The aim of this study was to evaluate the feasibility, safety and clinical outcomes of the ERAS programme after PD at a high-volume Chinese university referral centre. METHODS Between September 2014 and July 2016, a retrospective analysis of 166 consecutive patients who underwent PD at a tertiary referral care center was carried out. Ninety-eight patients who received conventional perioperative management (the conventional group) were compared with 68 patients who received ERAS programme (the ERAS group). The incidences of postoperative complications, length of stay, expenses, postoperative readmissions, and reoperation rates were compared. RESULTS A total of 166 patients who underwent PD were analysed (68 patients in the ERAS group, and 98 patients in the conventional group). There were no significant differences in mortality, reoperation, and readmission rates. The ERAS group had a lower morbidity rate than the conventional group (50% vs. 90.8%; P = 0.00), as well as a shorter length of hospital stay (7.5 vs 12 days; P = 0.00). Delayed gastric emptying was significantly reduced in the ERAS group (0 vs. 11.2%; P = 0.011). Pancreatic fistula (grade B,C) was significantly reduced in the ERAS group (14.7 vs 30.6%; P = 0.018). The median total hospital cost was also significantly reduced in the ERAS group (¥79790.40 vs ¥102982.81; P = 0.000). CONCLUSION The ERAS programme is feasible and safe in patients who underwent PD, and it can reduce postoperative complications and improve clinical outcomes.
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Affiliation(s)
- Juntao Dai
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yongjian Jiang
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China.
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Risk factors for complications of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. Int J Surg 2016; 37:71-78. [PMID: 27956112 DOI: 10.1016/j.ijsu.2016.12.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/12/2016] [Accepted: 12/07/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although bariatric procedures are considered safe, yet still they involve a risk of possible perioperative complications. Identification of risk factors for complications would allow for appropriate preoperative optimization of the patient, as well as reasonable postoperative care and early diagnosis and treatment of possible complications. The aim of this study was to determine the risk factors for perioperative complications after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). MATERIAL AND METHODS A retrospective analysis of prospectively collected data of patients operated for morbid obesity. Regarding postoperative complications defined as adverse events occurring within 30 days of the procedure. Factors associated with patient characteristics and those related to the surgical procedure were determined. 408 patients met inclusion criteria and were submitted to surgical treatment. LSG and LRYGB were performed in 233 and 175 patients, respectively. RESULTS Complications were observed in 30 (7.3%) patients. The maximum preoperative body weight and BMI, as well as body weight and BMI on the day of surgery were associated with increased complication rate. The type of the procedure did not influence perioperative complications (LRYGB vs. LSG; OR: 1.14; CI: 0.53-2.44; p = 0.74). Although operative time statistically significantly increased the risk of complications, it did not seem clinically relevant (OR: 1.01; CI: 1.00-1.02; p = 0.003). An increase in the number of stapler firings used significantly increased complication rate only in LSG group. CONCLUSION Longer duration of LSG and the increase in the number of stapler firings used during LSG should alert a surgeon to an increased risk of postoperative complications. In patients submitted to LRYGB the risk of possible complications increases with BMI.
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Bougie A, Aggarwal R. Enhanced Recovery Pathways in Bariatric Surgery: A Contemporary Review. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0160-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach. Surg Res Pract 2016; 2016:3561249. [PMID: 27504486 PMCID: PMC4967675 DOI: 10.1155/2016/3561249] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/14/2016] [Indexed: 02/07/2023] Open
Abstract
ERAS approach (Enhanced Recovery After Surgery) is a multimodal, perioperative pathway designed to achieve early recovery after surgery. ERAS has shown documented efficacy in elective surgery, and the concept of "multimodal" and "multidisciplinary" approach seems still to be of higher importance than each single item within ERAS protocols. New perspectives include the use of ERAS in emergency surgery, where efficacy and safety on outcome have been documented, and flexibility of traditional items may add benefits for traditionally high-risk patients. Obstetric surgery, as well, may open wide horizons for future research, since extremely poor data are currently available, and ERAS benefits may translate even on the baby. Finally, the concept of "outcome" may be extended when considering the specific setting of cancer surgery, in which variables like cancer recurrence, early access to adjuvant therapies, and, finally, long-term survival are as important as the reduced perioperative complications. In this perspective, different items within ERAS protocols should be reinterpreted and eventually integrated towards "protective" techniques, to develop cancer-specific ERAS approaches keeping pace with the specific aims of oncologic surgery.
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Challenges in the Management of Geriatric Obesity in High Risk Populations. Nutrients 2016; 8:nu8050262. [PMID: 27153084 PMCID: PMC4882675 DOI: 10.3390/nu8050262] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/12/2016] [Accepted: 04/25/2016] [Indexed: 01/26/2023] Open
Abstract
The global prevalence of obesity in the older adult population is growing, an increasing concern in both the developed and developing countries of the world. The study of geriatric obesity and its management is a relatively new area of research, especially pertaining to those with elevated health risks. This review characterizes the state of science for this “fat and frail” population and identifies the many gaps in knowledge where future study is urgently needed. In community dwelling older adults, opportunities to improve both body weight and nutritional status are hampered by inadequate programs to identify and treat obesity, but where support programs exist, there are proven benefits. Nutritional status of the hospitalized older adult should be optimized to overcome the stressors of chronic disease, acute illness, and/or surgery. The least restrictive diets tailored to individual preferences while meeting each patient’s nutritional needs will facilitate the energy required for mobility, respiratory sufficiency, immunocompentence, and wound healing. Complications of care due to obesity in the nursing home setting, especially in those with advanced physical and mental disabilities, are becoming more ubiquitous; in almost all of these situations, weight stability is advocated, as some evidence links weight loss with increased mortality. High quality interdisciplinary studies in a variety of settings are needed to identify standards of care and effective treatments for the most vulnerable obese older adults.
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